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Viewpoint: Do EPs Understand Paramedics?

Mr. Phelpsis a paramedic and a professor of ambulance science with the Emergency Management Academy.

I'm never quite sure if emergency physicians really understand paramedics. I know many have a good understanding of our skills and training, and that a few were once paramedics. But I'm not sure they understand the environment in which we work or the barriers we face in providing care.

Being a paramedic is a hard, dirty job, and most of us will not make it to retirement. Injuries happen constantly when lifting and moving people. EMTs and paramedics have injury rates higher than firefighters and other health care providers (Prehosp Emerg Care 2005;9[4]:405), and 74 percent of Fire Department of New York EMS employees also suffered an injury at some time in their career that resulted in back pain. (U.S. Fire Administration/FEMA; http://1.usa.gov/VHQfbA.) Yet less than 65 percent of EMTs and paramedics have either short- or long-term disability insurance. (National Highway Traffic Safety Administration; http://1.usa.gov/1jsbN1q.)

The profession can be deadly, too. A paramedic is almost as likely as a police officer to die on the job. A total of 114 EMTs and paramedics were killed (12.7 fatalities per 100,000) between 1992 and 1997, compared with 14.2 for police officers. (http://bit.ly/1rHySlW.) All that for a 2005 median national wage of $12.54 an hour, less than half of firefighters' $26.82 (and $4 less per hour than LPNs and LVNs. (NHTSA; http://1.usa.gov/1jsbN1q.) EMS as a result is a transitory career (at least for non-fire service systems). One study of New Jersey's hospital-based paramedic system found that no one in any of the 13 focus groups of six to 14 people each could name five paramedics who retired after completing years of service with a full pension. (New Jersey Department of Health; http://bit.ly/1iNrJAz.)

Part of the reason paramedics are poorly compensated is that medical insurance does not cover the true cost of providing EMS, which is rarely more than a break-even proposition. The payment system is designed so that a public subsidy for 911 services is required, and ambulances are mandated to accept Medicare, which is designed to cover the cost of the actual ambulance transport but do not pay for seen-but-not-transported patients or for 911 ambulances being available to respond. (CMS; http://go.cms.gov/VtSShP.)

EMS services are required to respond to all emergencies, so they all also accept Medicaid, but those rates are a joke: $189 for paramedic ambulance transport in Westchester County, NY, one of the richest U.S. counties. Commercial and self-pay rates are exorbitant as a result. The average ambulance rate in San Diego is $1,820, an eye-popping number explicitly designed to offset public insurance losses, private insurance preferred contracts, and non-payers. (San Diego Union-Tribune, June 24, 2013; http://bit.ly/1wKTI6F.) The only way to stay in the black when profits are fixed is to reduce costs, and the largest cost in any EMS system is employees. As a result, EMS has extremely few middle management positions. Salaries lag as a result in independent EMS systems where costs cannot be shifted, and the best talent leaves because there are no growth opportunities.

The lack of middle managers means EMS doesn't have the staff to participate in health care or government decision-making. A report by New York University revealed that EMS received less than five percent of all post-9/11 public safety funds, and lacked “vital response equipment, training, and education” because EMS providers “were often excluded from critical emergency planning efforts.” (NYU Center for Catastrophic Preparedness and Response, April 21, 2005; http://bit.ly/1pWYdsG.) Not being at the table means that public safety thinks EMS is a health care function, and health care thinks EMS is a public safety function. It's a Catch-22: We don't have people to send, so we don't get funded. We don't get funded, so we can't hire people.

We still can't decide, even after 40 years, the fundamental issue of what gives paramedics the right to their (limited) practice of medicine. Presumably, we work as physician-extenders under the license of a physician to make a diagnosis, define a treatment plan within protocols, and provide that treatment. But whose license? If we worked under our medical director's license, then we couldn't seek permission from on-line medical control to perform treatments that require physician approval. If we worked under the license of on-line medical control, we wouldn't be able to use the standing protocols designed by our system medical director. This basic lack of clarity inhibits our development into a real profession.

Paramedics are given enormous responsibility while being treated like peons. They perform a wide-ranging set of physician-level skills in the ambulance while experts are in conflict about whether paramedics make a diagnosis. (EMS1.com, Aug. 18, 2009; http://bit.ly/UQHHiq.) This, of course, is just stupid: Paramedics perform an assessment, make a diagnosis (and they are quite good at that [Prehosp Emerg Care 1997;1[1]:16]), and then develop a therapeutic plan according to a physician-defined medical protocol. But the fact that there is controversy about whether we diagnose highlights the incongruity between our (necessarily) highly independent practice and our low social standing within the health care hierarchy.

We have equivalent education to nurses and perform diagnosis and complex therapies, yet lack the professional status of nurses. My experience in New York City is that paramedics and nurses worked for the ED, and had zero professional conflict. But nearby New Jersey has a constant struggle for dominance in the same type of setting.

We are not in control of our profession. EMS has been hobbled by a broad level of physician domination over EMS: We function like children who do what they're told rather than professionals who collaborate with physicians even though we take ownership of all nonclinical aspects of paramedic care, quality, training, and regulation. Physicians should guide and oversee therapy in the field, but after 40 years of guidance, we need to stand on our own two feet.